Coast Mountain Expeditions, Ltd.

Please print out and complete this form, and mail it to the address at the bottom of the page.
 To print this page click on File then on Print top left of this browser page,
make sure your printer is turned on.


Trip selected ______________________________________________________________
Dates ____________________________________________________________________
Applicant's full name ________________________________________________________
Address __________________________________________________________________
City ______________________________________________________________________
Province/State _____________________________________________________________
Postal Code ________________________________________
Phone (Day) ____________________________(Evening) ___________________________
E mail Address_____________________________________________________________
Applicant's Age _________________  Height _______________  Weight ______________

Emergency Contact:
Name ____________________________________________________________________
Address __________________________________________________________________
Phone ____________________________________________________________________
Relation to applicant ________________________________________________________

If applicant is under 19:
Parent's name _____________________________________________________________
Address __________________________________________________________________
Place of employment _______________________________________________________
Work phone _______________________________________________________________

Note: Parents should sign the medical and waiver form. Registration should be accompanied by a letter of endorsement from parent


Name: ______________________________________ Birthdate: ____________________
Medical insurance plan: _____________________________________________________
Physical condition: _________________________________________________________
Allergies life threatening _____________________________________________________
Allergies non life threatening _________________________________________________
Date of last Tetanus inoculation or booster: _____________________________________
Are you on any medications (prescription or non-prescription)? yes ___ no ___
If yes, please specify: _______________________________________________________
Have you been under a doctor's care in the past 12 months? yes ___ no ____
If yes, please specify: _______________________________________________________
Do you have a chronic dissability or illness:
Epilepsy, diabetes, susceptibility to colds, headaches, nosebleeds, fainting, asthma, hay fever, emphysema, or others:__________________________________________________
History of joint injury (tendonitis, bursitis, sprain, dislocation, or other):
Eyesight ___ Excellent ___ Good ___ Fair ___ Poor ___ Glasses* ___ Contacts
*If you are dependent upon glasses for adequate vision, a spare set should be brought with you.
Do you have any physical limitations? __________________________________________
Do you feel that you have any psychological limitations? (i.e.. fear of water, fear of heights, etc.) Please explain:_________________________________________________

The above medical information is complete and accurate. If any of the information changes, I will inform the instructors so that the changes can be recorded. I have read the trip outline and physical requirements. I am in good physical condition to participate. I have read the disclosure information and understand the possible hazards that may be encountered on the trip. I agree to adhere to the rules and regulations set up by the leaders of the trip to minimize risk and ensure safety. I have read the Disclaimer of Liability of Coast Mountain Expeditions. Ltd. (Safety and Responsibility, the "fine print") and agree to be bound by its terms and conditions

Signature of Applicant_______________________________________________
Date ________________________

Parent's Signature (if applicant under 19)________________________________
Date ________________________

Coast Mountain Expeditions, Ltd.  Phone (250) 285-2823
MAIL TO: Box 25, Read Island, Surge Narrows, BC, Canada V0P 1W0